NHS trusts to face new obligation to publish preventable death statistics

NHS trusts will be required to collect and publish the number of preventable deaths recorded on a hospital by hospital basis from next year, Jeremy Hunt has announced.

A report by the Care Quality Commission (CQC) found “system-wide” problems in the way the NHS investigates preventable patient deaths with family members feeling left in the dark about failures in care.

The Health Secretary said requiring trusts to publish data on avoidable deaths will help patients and the public see which hospitals are learning from their mistakes.

The CQC report found NHS Trusts in England are “immediately on the defensive” when someone dies and highlights a string of problems with the investigation process – including a level of “acceptance and sense of inevitability” when people with a learning disability or mental illness died earlier than they should have.

The CQC also warn that the NHS is missing opportunities to learn from patient deaths which means mistakes could be repeated in the future while grieving families are not being included or listened to during investigations.

Mr Hunt said the Government will be accepting all of the recommendations made by the CQC as he delivered a statement to MPs in the House of Commons.

He said: “From March 31 next year the boards of all NHS trusts and foundation trusts will be required to collect a range of specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned on a regular basis.

“This will include estimates of how many deaths could have been prevented in their own organisation and an assessment of why this might vary positively or negatively from the national average based on methodology adapted by the Royal College of Physicians from work done by Professor Nick Black and Doctor Helen Hogan.

“We will be requiring trusts to publish that information quarterly in accordance with regulations I will lay before the House so that patients and the public can see whether and where progress is being made.”

Mr Hunt said the UK would be the first country in the world to publish data on avoidable deaths at a hospital-by-hospital level.

Hospitals will also be required to publish evidence of the action taken as a result of the learning of lessons from preventable deaths.

Mr Hunt said: “Alongside that data they will publish evidence of learning and action that is happening as a consequence of that information.”

As well as the new data requirement, the CQC report also recommended setting a national standard into how NHS trusts investigate deaths and proposed appointing a senior board member at each organisation to lead on patient safety.

NHS Trusts carry out investigations into deaths which may have been prevented to examine issues of accountability and to find out what went wrong.

The CQC investigation was launched by the Health Secretary following the review into the case of Connor Sparrowhawk, who died while being cared for at Southern Health NHS Trust.

The family of the 18-year-old, who had a learning disability and epilepsy, raised concerns about the way his death was being investigated.

Following their campaigning, an investigation concluded that the teenager’s death was entirely preventable.

Mr Hunt said that, as a result of the review, there will be a new emphasis placed on the way in which patients with a learning disability are treated.

He said: “Finally, because the report identified particular concerns about the treatment of people with learning disabilities, we will take two further actions.

“In acute trusts we will ask for particular priority to be given to identifying patients with a mental health problem or a learning disability to make sure that their care responds to their particular needs, and that particular trouble is taken over any mortality investigations to ensure wrong assumptions are not made about the inevitability of death.

“We will also ensure that the NHS reviews and learns from all deaths of people with learning disabilities in all settings.”

Shadow health secretary Jonathan Ashworth described the CQC report as a “wake-up call” and the treatment of bereaved families as “shameful”.

He backed the plan to create a national framework setting out how NHS trusts should investigate deaths.

“We strongly therefore welcome the recommendation of a national framework and the specific measures the Secretary of State has outlined today,” he said.

However, Mr Ashworth stressed the need for investment to be brought forward by the Government to ensure the recommendations are adequately implemented.

He said: “For a national framework such as this to succeed and the proposed measures you have outlined to succeed investment will be necessary.”

Mr Ashworth also linked the report to “chronic staff shortages” across the NHS and funding problems in the social care sector.

“The Secretary of State is aware of the wider pressures on the service,” he said.

“Will you acknowledge that the cuts to social care and the failure to provide social care with extra investment in the autumn statement two weeks ago are leaving hospitals dangerously overstretched with patients at risk of harm?”

Mr Hunt said there is a need to “get away from a blame culture” in the NHS as he addressed the funding issue.

“The point I would make here is actually this is a win-win because avoidable harm and death is incredibly expensive for the NHS,” he said.

“The time it takes to do investigations when things go wrong is utterly exhausting for the doctors, nurses, managers involved and they would much rather be doing frontline care.”

MPs across the political parties welcomed that the Government is implementing all the recommendations, and stressed that families must be fully included.

Conservative MP Mark Harper, chairman of the All Party Parliamentary Group (APPG) on learning disability, said it was “chilling” that CQC investigators found a level of acceptance and inevitability when people with a learning disability died.

He stressed there can be “no tolerance” with treating such deaths as less important than other patients.

Labour MP Fiona Mactaggart (Slough) welcomed the review and urged ministers to ensure it includes unexpected deaths in care settings other than the NHS.

She said: “When I was first elected, Longcroft Home, which purported to be a care home for learning disability, was actually a torture chamber for people with learning disabilities.

“We’ve ended that kind of thing, but we do need to ensure that in other care settings where there are unexplained deaths of people with learning disabilities they are fully investigated and they feed into this review.”

And Labour MP Tracy Brabin (Batley and Spen) asked the Government “to commit” to Nice publishing safe nursing staffing levels as recommended in the Francis Report.

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